Does Your Agency Set a Limit on Visits?

[RachRN66]

I am a long time (>10 year with this company and >20 years nursing) employee of a not for profit agency. We are owned by our local "owner hospital". But we are not managed by that local hospital, we have our own set of ceo/admin people. My agency says that they put all our profits back into the owner hospital, and last year it was reported by our administration that we put >22M$ back into said owner hospital health system. Because we are "hospital owned" we have to take all patients that they refer to us, we can not "cherry pick" profitable insurance patients. We acecpt the indigent, the Medicaid, the Private insurance, and the Medicare and Managed Medicare patients. Back in the summer there was a rush for management to have meetings with all the field staff and explain the "changes in health care" and how it would impact us as an agency. Suddenly with some of the "not so profitable managed Medicare" patients we were limited to 5 visits, regardless of their needs, co-morbidities etc. The SOC nurses were instructed to write ONLY 5 visits total, usually over a 2 week period of time. And it was said that we could "conference with our managers" if we needed any further visits. I have had some very challenging patients with said insurances. We are told by management that we get so many of these insurance cases because none of the other Home Health Agencies in the area will take them. The other Home Health agencies "cherry pick" the profitable insurance companies and leave us with the rest, which results in a high number of these patients. So 5 visits it has been for these patients. NO more, NO less. When you do call into a manager and conference about needing more visits they say, "You have done all you can do, now teach and get out". Really?? It doesn't matter if the patient doesn't have a clue how to manage their disease processes or take their medications correctly. I even document in the clinical notes that patient has not met xyz goals, conferenced with Sally Smith, RN, Care Manager, and they say "You have done all you can do, so teach and get out." I document these instences to cover my A$$.

Then later this week we got another e-mail from above management that says the nursing trend in some of our smaller branch agencies is that we do not have enough visits to keep the nursing staff productive so they are going to tweak our process and give us 8 visits per episode on these managed care patients. Not because that is what a trained, educated professional assesses but because we aren't making money. I wrote a long email to the "above management" toda and asked them what ever happened to individualized care based on the patient needs, and that the medical profession is not a "one size fits all" model.

Curious, does your home health agencies "cherry pick" patients based on payor source? Do you ever get mandated by upper management to do only 5 visits or less on certain payor sources? Or even 8 visits for that matter? How legal is this?

[caliotter3]

While I can not speak to your specific questions, I can state that I have been reminded that certain new clients were to be treated witb deference due to their private pay, insurance payor, or wealthy status. I imagine that agencies do a lot of things differently for clients that bring in more money. Not surprising.

[Isabelle49]

You say you work for a not for profit agency, but it sounds to me like they are all for profit with the limit on visits. I'm not sure how Medicare managed insurers pay, but I can tell you that regular Medicare pays an amount based on many factors, diagnoses and certain items on the OASIS. If the minimum number of 5 visits is completed, the Home Health company is paid the same amount as if they saw the patient 9, 18, 27 and more times in the episode. Now, if a Medicare patient is seen for less than 5 visits, payment is calculated at a daily rate, total amount based on HHRG/60days X number of days seen (

[KateRN1]

Medicare Managed care does not pay in the same way as fee-for-service Medicare, so it's a completely different ballgame. Generally, the agency must obtain authorization from the managed care agency prior to the SOC and sometimes you only get authorization for the initial assessment. The office must then submit a request for authorization for further visits and additional disciplines, which the insurer may or may not grant depending on the OASIS and other information included in the request. It's not always up to the agency how many visits they get to do and the payment is generally less than traditional Medicare.

Agencies don't always "cherry pick" based on insurers. You have to be approved to be an in-network provider which is a lot of paperwork and if you consider the additional man-power expense involved in dealing with the authorization requests, many agencies choose not to be providers for managed care insurers.

Remember, even non-profit agencies have to bring in more money than the spend otherwise they don't stay in business. Non-profit doesn't mean that they don't have to be business savvy, it means that whatever profits they incur are redirected into the business rather than the owners or shareholders.

Regardless of payor source, all agencies are having to "work smarter not harder" and maximize what can be accomplished at each visit. The push for all of us is to limit utilization and discharge earlier--and that is true across the entire health care spectrum, not just home care. We all have to do a better job at including family, friends, and other caregivers into our teaching plans and assisting patients to become more independent sooner. This is the current reality of health care and especially home care.

[lossforimagination]

The agency I work for is very small and ONLY takes Medicare referrals.